THE THYROID APPARATUS 99 



is probably due to an adequate degree of activity on the part of 

 the apparatus which regulates heat production. The rise in tem- 

 perature which occurs shortly before death (Kocher) is probably 

 due to failure on the part of this apparatus. 



The increased production of heat is frequently associated with 

 an augmented demand for, and consumption of, albumin, together 

 with a negative N-balance, though the latter is not invariable. The 

 metabolism of nitrogen varies with the fluctuating course of the 

 disease and may, for longer or shorter periods, approximate to 

 the normal. The albumin losses and the toxic decomposition of 

 albumin may be counteracted, even when the disease is at its 

 height, by a diet containing albumin, or by a diet containing 

 carbohydrates but free from nitrogen (Riidinger). The fats also 

 undergo decomposition. In connection with the metabolism of 

 the carbohydrates, it must be borne in mind that the assimilation 

 of the carbohydrates is reduced in Graves's disease, and that for 

 this reason an alimentary glycosuria is easily provoked (Ludwig 

 and F. Kraus). The feature which characterizes the metabolism 

 of Graves's disease is the increase in the total amount of oxidation. 



An increased metabolism of mineral salts has not as yet been 

 proved, though A. Kocher describes an increase in the excretion 

 of phosphorus. Investigation in this direction has recently been 

 undertaken by Scordo and Franchini. 



Certain features of Graves's disease are the clinical opposites 

 of those seen in myxcedema. These are : the thin, soft, smooth, 

 moist skin ; the general nervous excitability ; the restlessness and 

 haste ; the tremor ; the exaggerated reflexes ; and the mental 

 exaltation and psychic changes, which may even amount to 

 psychosis. 



There are certain symptoms which are common to both 

 Graves's disease and cachexia strumipriva as, for instance : trophic 

 disturbance of the skin ; oedema ; dryness, falling and blanching 

 of the hair ; friability of the nails ; abnormal pigmentation ; and 

 increased salivary and lachrymal secretions. 



The changes in the blood are the same in both conditions. 

 There is an increase of mononuclear leucocytes and a remarkable 

 increase in the eosinophile cells. And in both conditions there are 

 changes in the activity of the sexual glands, which are shown, in 

 women, by a cessation of the menstrual processes. 



It is interesting to note, in this connection, that symptoms 

 resembling those of Graves's disease are associated with other 

 pathological conditions. Such are the forme fruste seen in 

 ^chlorosis (Chvostek) ; the pseudo-chlorosis, encountered in 

 goitrous districts, and characterized by swelling of the thyroid, 

 increased cardiac activity, mental excitement, fatigue, and pallor, 

 without, however, chlorotic changes in the blood (F. v. Miiller) ; 

 and, finally, the symptoms resembling those of Graves's disease, 

 which are seen at the climacteric (Gluzinski). On the one hand. 



